Evaluation of Degenerative Lumbar Disc Surgeries

Original Research Article

Indian Journal of Orthopaedics Surgery 2016;2(1):52-63 52

Evaluation of Degenerative Lumbar Disc Surgeries

Anubhav Sharma1, Pradeep K Singh2, Sohael M Khan3,*,

Shounak Taywade4, Ankit Chintawar5, Sparsh Naik6

1,4,5,6Junior Resident, 2Professor and Head, 3Assistant Professor, Dept. of Orthopaedics,

Jawaharlal Nehru Medical College, Wardha, Maharashtra, India

*Corresponding Author: E-mail: [email protected]

Abstract Background: Back pain has been known since the start of written history, probably the first report of back pain and sciatica can

be found in an ancient text, the so-called Edwin Smith Surgical Papyrus presumably written around 1550 B.C.1 Although

backache (with or without sciatica) is a benign often self -limiting condition (Macnab). 2 The cost of both time lost from work

(with loss of productivity) and medical care, as well as the cost of litigation and disability claims, make back pain an industry

unto itself.

Purpose: The main purpose of this study was to evaluate the clinical, radiological outcome of the lumbar disc patients managed

surgically and to compare the results of different surgeries performed.

Methods: This study was prospective, non-randomized, cohort study it was carried out in the Department of Orthopaedics,

Acharya Vinoba Bhave Rural Hospital, Wardha, between August 2013 – 2015. Patients with more than 18 years were included

with persistent bothersome sciatic pain, despite conservative management for a period of 6-12 weeks. All the patients with

progressive neurological involvement during a period of conservative treatment. All the patients with cauda equina syndrome or

impending cauda equina syndrome.

Results: Out of total 67 patients the mean age was 49.85±8.75 years ranging from 40 to 72 years. Male gender was

predominantly forming 66% of the sample size whereas 34% of females. All the patients had radicular pain, 26 out of 67 patients

had left sided radiculopathy and right-sided radiculopathy was observed in 21 patients whereas 20 patients had bilateral

radiculopathy. After MRI 34 patients had extrusion of disc, whereas 17 patients showed sequestrated disc, protrusion of disc was

observed in 12 patients, whereas disc bulge was observed in 4 patients. 42% of patients were operated by laminectomy, 33 %

patients were operated by microscopic discectomy and minimum 25% of patients were operated with microendoscopic

discectomy. L4-L5 level was the most common level to get involved. Mean Pre-operative VAS score for male patients was 6.64

and female patients was 6.78, which was reduced to 3.14 and 3.48 respectively after 6 months of operative management. Mean

Pre-operative Oswestery score for male patients was observed to be 44.05 and female patients was 44.87, which was reduced to 24.95

and 27.83 respectively after 6 months of operative management. Complications in all three surgeries were observed.

Conclusion: Minimally invasive techniques in all areas of surgery have gained momentum in recent years. Spinal surgery has

been no exception. Unfortunately, minimally invasive techniques have often been equated with minimally effective procedures.

We understand that the micro endoscopic discectomy and microscopic discectomy techniques are superior to the standard

discectomy technique for the treatment of single level lumbar disc herniation’s with regard to pain relief, clinical outcome and

functional outcome, volume of blood loss, systemic repercussions, and duration of hospital stay. However, technical expertise

and learning curve of the technique could be the limitation. Minimally invasive surgeries are cost-effective treatment for lumbar

herniated discs. Results and complications were comparable with those associated with standard discectomy techniques. Patient

satisfaction was high, and a cost savings was realized.

Keywords: Degenerative, Lumbar Spine, Disc Surgeries, Microscopic Discectomy, Laminectomy, Decompression

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DOI: 10.5958/2395-1362.2016.00009.8

Introduction

The first published report of lumbar disc herniation

with radiculopathy was written by Mixter and Barr in

1934. Surgical treatment was not widespread until the

1950s. Today, lumbar discectomy is one of the most

commonly performed elective operations. Lumbar disc

disease accounts for a large amount of lost productivity

in the workforce in the Indian population. Although

most people experience back pain during their lifetime,

only a fraction experience lumbar radiculopathy or

sciatica as a consequence of root compression or

irritation. Almost 5% of males and 2.5% of females

experience sciatica at some time in their lifetime.

In the industrialized countries, back pain today is

the second most common reason for seeking medical

care.3 Everybody belonging to this group of

‘BACKPAIN’ wants an answer to their sufferings and

in process the Governments health care budget’s share

for backache goes up to billions per year and increasing

year after year. The economic burden of spinal

disorders includes:

1) Direct - concern medical expenditure

Anubhav Sharma et al. Evaluation of Degenerative Lumbar Disc Surgeries


2) Indirect - consist of lost work output attributable

to a reduced capacity for activity, and result from

lost productivity.

3) Intangible costs are the most difficult to estimate.

Intangible costs include psychosocial burdens

resulting in reduced quality of life, such as job

stress, economic stress, family stress, and

suffering. The direct and indirect costs are

considerable and their management utilizes a

significant part of the gross national product of

many countries. However, back pain has a severe

impact on the individual, families, and society. 4

When a fragment of nucleus herniates, it irritates

and/or compresses the adjacent nerve root. This can

cause the pain syndrome known as sciatica and, in

severe cases, dysfunction of the nerve.

Most lumbar disc herniation’s (lumbar disc

diseases) are preceded by bouts of varying degrees and

duration of back pain. In many cases, an inciting event

cannot be identified. Pain eventually radiates into the

leg. It may be characterized as achy, burning, or similar

to an electrical shock and is often described as a

shooting or stabbing pain. The distribution of the leg

pain is somewhat dependent on the level of nerve root

irritation.

On examination, patients may be neurologically

normal, may have a profound radiculopathy, or may

even demonstrate a cauda-equina syndrome. A positive

straight-leg raising sign is almost always present.

However, a crossed straight-leg raising sign may be

even more predictive of a lumbar disc herniation

(lumbar disc disease). A disc herniation (lumbar disc

disease) most frequently irritates the displaced nerve

root.

Aim & Objective The aim of the study was to evaluate clinical,

functional and radiological outcome of lumbar disc

surgeries and to compare the results of different

surgeries performed for lumbar disc.

Method and Material The present study was carried out in the

Department of Orthopaedics, Acharya Vinoba Bhave

Rural Hospital, Wardha, between August 2013 – 2015.

The study design was prospective, non-randomized,

cohort study.

Patients with more than 18 years were included

with persistent bothersome sciatic pain, despite

conservative management for a period of 6-12 weeks.

All the patients with progressive neurological

involvement during a period of conservative treatment.

All the patients with cauda equina syndrome or

impending cauda equina syndrome.

Patients with disc prolapse at more than one level,

operated earlier for the disc pathology, who required

spinal fusion surgeries and patients with associated

vertebral fracture, infective, or neoplastic disease of the

spine were excluded

Observation & Results Out of total 67 patients the mean age was

49.85±8.75 years ranging from 40 to 72 years. The

distribution curve was bell shaped with rounded peak at

fourth decade and tapering ends at extremes of age.

Maximum patients were from fourth decade of life. The

proportion of patients in different age group was

analyzed using chi-square test. Male gender was

predominantly forming 66% of the sample size whereas

34% of females.

The mean age for male patients was found to be

49.84±8.58 years, which was nearly same for the

female patients, mean age 49.87±9.25 years. Minimum

age for female was 40 years and maximum 70 years and

minimum age for male was 40 and maximum 72 years.

All the patients had radicular pain, 26 out of 67 patients

had left sided radiculopathy and right-sided

radiculopathy was observed in 21 patients whereas 20

patients had bilateral radiculopathy.

MRI findings of the patients in the study were

observed, 34 patients had extrusion of disc, whereas 17

patients showed sequestrated disc, protrusion of disc

was observed in 12 patients, whereas disc bulge was

observed in 4 patients. Changes in MRI of the patients

were observed, 39 patients had ligamentum flavum

hypertrophy, whereas 38 patients had facetal

hypertrophy, modic changes were observed in 25

patients and 9 patients showed pars defect without

listhesis.

Maximum 42% of patients were operated by

laminectomy, 33% patients were operated by

microscopic discectomy and minimum 25% of patients

were operated with microendoscopic discectomy. The

Proportion of number of surgeries to type of surgery

was found to be significant.(Chi-square test p=0.001

<0.05).

Most of the surgeries were done in the patients of

age group of fourth decade. 50% of all type of surgeries

was done in fourth decade. Microscopic group had

patients with minimum age of 40 and maximum age of

70. Whereas, microendoscopicscopic group had

youngest patient of age 40 years and eldest 61years.

However the distribution of number of surgeries in

different age group was statistically significant. (chi

square test p=0.0001(p<0.05).

Laminectomy group patients had higher mean age

54.25±9.656 years as compared to microscopic and

micro endoscopic surgery group 46.5±6.940 and

46.95±6.088 years respectively. The mean age of three

groups was compared and the difference was found to

be statistically significant.(Analysis of variance

p=0.01(p<0.05).

When comparison between time period of

symptoms and type of surgery was done it was found

that the patients who had undergone microendoscopic



discectomy had less time between onset of symptoms

and surgery which was 13.94±6.28 months as compared

to microscopic discectomy which was 19.36±12.11

months and for standard laminectomy it was

24.14±12.80 months. The difference was found to be

significant. (one way ANOVA test p=0.016 p<0.05).

L4-L5 level was the most common level to get

involved and accounted for 72% of total single level

surgeries. L5-S1 accounted for 25% of total surgeries

whereas L3-L4 level surgeries accounted for only 3%

of total patients. However, the distribution was found to

be significant. (chi- square test p=0.025; p<0.05).

The mean VAS scores of pre-operative, post-

operative and 6 months follow up VAS scores were

compared, there was significant reduction in the

postoperative VAS scores in all three surgeries and the

reduction in mean VAS score was maximum in

microendoscopic discectomy by 4.18, followed by

microscopic discectomy by 3.37 and laminectomy by

3.04. However, the difference was found significant.

(One way ANOVA test p=0.0001(p<0.05).

The mean oswestery scores for pre-operative, post-

operative and 6 months follow up were compared.

Maximum reduction in mean Oswestery score was

found in microendoscopic discectomy by 22.71, for

microscopic discectomy score reduced by 17.45 and

minimum reduction in mean Oswestery score was

found in standard laminectomy by 16.50. However, the

difference was found significant in all the thre

surgeries. (one way ANOVA p=0.0001 p<0.05).

The mean hospital stay for microendoscopic

discectomy was 1.82±0.72 days, for laminectomy group

patients was 6.46±2.15 days, whereas for microscopic

discectomy hospital stay was 4.23±0.75 days. The mean

hospital stay in all three surgeries was compared. The

difference was statistically significant (one way

ANOVA test p=0.016 (p<0.05).

A Complications in all three surgeries were

observed, laminectomy had maximum number of

complications, 6 patients did not had pain relief, dural

tear was observed in 3 patients, however 3 patients had

superficial surgical site infections, discitis was observed

in 2 patients, however 1 patient had reherniation.

Whereas, only 2 patients did not have pain relief after

microscopic surgery, superficial infection was observed

in 1 patient, however 1 patient had discitis and

reherniation was observed in 1 patient. However, only 1

patient did not relieve of pain after microendoscopic

discectomy.

Table 1: Age description

Statistics

Age

Number of patients 67

Mean 49.85

Std. Error of Mean 1.069

Std. Deviation 8.751

Variance 76.583

Range 32

Minimum 40

Maximum 72

Graph 1: shows distribution of age



Table 2: Shows Gender Wise Distribution According to Mean Age

Group Statistics p value

Gender Number of

patients Mean

Std.

Deviation

Std. Error

Mean

.990

(p>0.05) Age Male 44 49.84 8.586 1.294

Female 23 49.87 9.255 1.930

Graph 2: Shows Distribution of Radicular Symptoms

Table 3: Distribution of patients according to stages of herniated disc

Herniated Disc

Frequency Percent

Disc Bulge 4 6

Protrusion of Disc 12 18

Extrusion of Disc 34 51

Sequestrated Disc 17 25

Total 67 100

Graph 3: Changes in MRI

BILATERAL30%

LEFT39%

RIGHT31%

0

5

10

15

20

25

30

35

40

Ligamentum

Flavum

Hypertrophy

Facetal

Hypertrophy

Modic Changes Pars Defect

39 38

25

9



Table 4: Distribution of patients according to types of surgeries

Type of Surgery Number of patients Percentage

Laminectomy 28 42

Microendoscopic discectomy 17 25

Microscopic discectomy 22 33

Total 67 100

Table 5: Correlation between different age group with type of surgeries

Age

group Laminectomy

Microendoscopic

discectomy

Microscopic

Discectomy Total p value

31-40 1 3 3 7

0.0001

41-50 14 9 16 39

51-60 5 4 2 11

61-70 7 1 1 9

71-80 1 0 0 1

Total 28 17 22 67

Graph 4: shows correlation between type of surgery and mean age

Table 5: Distribution of Level of operation among total number of patients

Level of operation Number of patients Percentage

L3-L4 2 3

L4-L5 48 72

L5-S1 17 25

Total 67 100

42

44

46

48

50

52

54

56

Laminectomy Microendoscopic

discectomy

Microscopic

discectomy

54.25

46.94 46.5

Age(mean)



Table 6: Correlation between type of surgery and pre-operative,

post-operative and 6 months follow up VAS Score

Descriptives Number of

patients Mean

Std.

Deviation p value

Pre-operative

VAS

Laminectomy 28 7.36 .678 .000

Microendoscopic discectomy 17 6.18 .728 .000

Microscopic discectomy 22 6.23 .612 .000

Post-operative

VAS

Laminectomy 28 6.57 .959 .000

Microendoscopic discectomy 17 4.65 1.272 .000

Microscopic discectomy 22 5.18 .795 .000

6 months follow

up VAS

Laminectomy 28 4.32 1.090 .000

Microendoscopic discectomy 17 2.00 1.173 .000

Microscopic discectomy 22 2.86 1.082 .000

Graph 5: shows correlation between type of surgery and mean pre-operative,

post-operative and 6 months follow up VAS Scores

Table 7: Correlation between type of surgery and pre-operative,

post-operative and 6 months Oswestery Score Score

Number of

patients Mean

Std.

Deviation p value

pre operative

oswestery score

Laminectomy 28 48.29 4.545 0.0001

Microendoscopic discectomy 17 39.18 4.004 0.0001

Microscopic discectomy 22 43.27 3.120 0.0001

post operative

oswestery score

Laminectomy 28 47.93 10.059 0.0001



6 months

oswestery score

Laminectomy 28 31.79 11.396 0.0001



7.36

6.57

4.32

6.18

4.65

2

6.23

5.18

2.86

0

1

2

3

4

5

6

7

8

Pre-Op VAS Score Post-Op VAS Score 6 months VAS Score

Laminectomy Microendoscopic discectomy Microscopic discectomy



Graph 6: Shows correlation between type of surgery and pre-operative,

post-operative and 6 months mean Oswestery Score

Graph 7: Shows correlation between type of surgery and mean of hospital stay

Graph 8: Shows correlation between mean pre-operative and mean 6 months values of VAS and Oswestery

scores

48.29 47.93

31.79

39.18

33.65

16.47

43.2738.55

25.82

0

10

20

30

40

50

60

Pre-Op Oswestery Score Post-Op Oswestery Score 6 months Oswestery Score

Laminectomy Microendoscopic discectomy Microscopic discectomy

0

2

4

6

8

Laminectomy Microendoscopicdiscectomy

Microscopicdiscectomy

6.46

1.82

4.23

Hospital stay(Days)

0

20

40

60

80

100

120

VAS Score Oswestery score FIM Score

6.69

44.33

92.76

3.25

25.94

113.57

Pre-Op Scores 6 Months Scores



Table 8: Distribution of complications among three surgeries

Complications

Pain Not

Relieved

Dural

Tear

Superficial

Infection Discitis Reherniation

Laminectomy 6 3 3 2 1

Microscopic Discectomy 2 0 1 1 1

Microendoscopic

Discectomy 1 0 0 0 0

Radiological and Clinical Photograph

CASE 1: Pre-Operative X-ray and MRI

Case 2: Pre Operative X-ray and MRI



Discussion The mean age of our study group was 49.85±8.75

years, which is comparable to other studies. Wang et

al.5, Righesso et al.6 and Mariscalco et al.7 observed

comparable mean age in their study. The explanation to

this can be that, the young- middle age group of

population are the most productive age of the society

and indulge in outdoor activities, which involve heavy

strenuous work.

Age group and gender distribution were correlated

and we observed that male had a mean age of

49.84±8.58 years and female patients had a mean age of

49.87±9.25 years. However the difference was

statistically insignificant.

VAS score is one of the leading indicators for

verifying the effects of interventions. However, low

back pain (LBP) has multiple causes, while sciatica is a

unique symptom of Lumbar disc herniation. So sciatica

could always be relieved after the surgery. Thus,

compared with LBP, the relief of sciatica (leg pain)

would be a more appropriate choice to evaluate the

effects of the surgery.

In present study microendoscopic discectomy

shows maximum reduction of VAS score in comparison

to microscopic and laminectomy surgery which is

comparable to international literature. To support our

study, Ryang et al.8, Tulberg et al.9, had similar findings

for microendoscopic discectomies. Katayama et al.10,

Teli et al.11 observed that patients VAS scores were as

low as normal. Alistair et al.12, Tulberg et al.9 observed

same results from microscopic discectomy. For

laminectomy Alistair et al.14, Fritzell et al.13 observed

comparable results with the present study. Righesso et

al.4 observed zero VAS score value in their both type of

surgical patients.

Turner J A et al.14 performed a study and observed

that success rate in terms of Oswestry Disability Index

of the microendoscopic discectomy was as high as

90%; excellent results were obtained in 80% patients in

microscopic discectomy patients. However, in

laminectomy patients, the success rate was 70% only.

In a historical meta-analysis, the success rate was 64%

only15. Our results in terms of Oswestry Disability

Index were much better as compared with study done

by Iguchi et al16 on traditional open laminectomy, in

which only 56.7% patients obtained good or excellent

results.17

With MED, the bony destruction was limited at the

interlaminar window and most of the facet joints are

preserved. Our study confirmed that MED is a good

surgical option to decompress the herniation while

preserving the intrinsic stability. Ng et al 18 found a

statistically significant increased risk of poor outcome

for Oswestry Disability Index and Low Back Pain

Outcome Score (but not for visual analog scale) if the

duration of sciatica exceeded 12 months prior to

surgery. In our study after 6 months Oswestery score is

16.47 which is comparable to international studies, Ulf

S Nerland et al19, John A et al20.

In the present study the reduction of Oswestry

score was significant for microscopic discectomy too.

Bhavuk Garg et al21 found 6 months follow up

Oswestry score 14.05 which is comparable to our study

25.82±7.19. In microscopic discectomy small incision

and less muscle injury and small fenestration window

accounts for less instability and soft tissue damage with

better healing and early mobilization when compared

with open laminectomy.

Oswestery score for standard laminectomy has

been studied in literature. Sun Zhuoran et al.22 and Ulf

S Nerland et al.23 observed significant reduction in open

Laminectomy, present study shows comparable results

31.79±11.40 with Sun Zhuoran et al.22 and Ulf S

Nerland et al.23, Oswestery score after 6 months.

However, Memduh et al.24 observed after open

laminectomy reduction of oswestery scores was

average. Our results were comparable to Sun Zhuoran

et al 22 and Ulf S Nerland et al23.

In our study 72% of the patients had disc prolapsed

at L4-L5 level which is comparable worldwide with

other studies like Cao Peng et al.9 shows(65%), Bhavuk

Garg et al.21 (75%) found single level pathology at L4-

L5 level. L4-L5 level is most vulnerable for disc

herniation. Pradeep K. Singh et al.25 concludes that the

common level for disc herniation involve L4-L5 of

lumbar spine due to weak inherent property of annulus



fibrosus and posterior longitudinal ligament at L4-L5

level.

As a general rule duration of symptoms was

directly proportional to outcome of surgery. The

patients who had surgery within 12 months of

symptomatology do better. A recent prospective study

by Rihn et al.26 in (Spine Patient Outcomes Research

Trail [SPORT])27 concludes that patient with symptoms

duration of 6 months or less had better outcomes (with

conservative or operative treatment) compared to

patients with symptoms duration of more than 6

months. However, there were significant baseline

differences in the two groups. These differences

included the type of herniation of nucleus pulposus, the

presence of neurological deficit, operative time,

percentage of patients who reported depression,

percentage of patients who perceived that the problem

was getting worse and percentage of patients who had a

preference for surgical treatment. Silverplats et

al.28 found duration of leg pain of <6 months and

duration of sick leave of <2 months was related to

better outcome. Hurme et al.29 found long duration of

preoperative sciatica (more than 2 months) was a

predictor of poor results.

Although there was no randomization but we found

in our present study that the patients who presented

early in 13.94±6.28 months had undergone microscopic

discectomy as compared to microscopic discectomy for

which patients presented in 19.36±12.11 months and

laminectomy for which patients presented in 24.14±

12.80 months.

Duration of hospital stay was primarily dependent

on postoperative mobilization of the patients. We

mobilized our patients as early as 1.82 days (mean) for

the patients who had MED, which was comparable to

many studies whereas for fenestration surgeries and

standard laminectomy it was 4.23 and 6.46 respectively.

Patients were discharged same day after post-op

mobilization.

Data regarding hospital stay were available in eight

studies including Ryang et al8, Tulberg et al.9,

Katayama et al10, Righesso et al6, all reported a

significant difference between the MED and

laminectomy group. The length of hospital stay varies

widely. In different reports the post-operative stay

ranged from 1.1 to 8.5 days30.

In our study we observed that ligamentum flavum

hypertrophy was present in 58% of patients, facetal

hypertrophy in 57%, modic changes in 37% and pars

defect in 13% of patients. Brinjikji W et al.31 concludes

that MR imaging evidence of disc bulge, degeneration,

extrusion, protrusion, Modic changes, and spondy-

lolysis are more prevalent in adults 50 years of age or

younger with back pain compared to asymptomatic

individuals. Takatalo J et al.32 concludes that

herniation’s were most likely in the subjects with recent

onset or persistent (3-yr period) low back symptoms,

when compared in subjects with no symptoms.

This is in keeping with the 1986 statement on the

role of micro discectomy in relation to standard

discectomy in which Hudgins wrote, “My concept of

micro-lumbar discectomy is that it consists of the

ability to do all the surgical maneuvers of standard

partial hemi laminectomy that have stood the test of

time, but through a much smaller incision.” It is

important that the complication rate associated with the

microscopic lumbar discectomy is comparable with that

in standard micro discectomy series. In our current

series there was a 5.9% wound infection rate, a 4.4%

discitis rate, and a 4.4% dural tear rate. These rates

compared favorably with those reported by Williams et

al.33 (0, 0, and 0%, respectively), Ebling et al.34 (3.3,

0.8, and 3.9%, respectively), Caspar, et al35. (0.7, 0.7,

and 6.7%, respectively), and Pappas, et al 36,(7.2, 0.5,

and 1%, respectively).

Our reoperation rate was 3%. This included one

recurrence of disc prolapsed at the same level and same

side, whereas one patient had herniation on

contralateral side of same level and were managed

conservatively. Whereas, one patient developed

refractory backache and required fusion eventually.

The aforementioned authors reported reoperation rates

of 14, 5.5, 5.7, and 3%, respectively.

In our study success rate was very high for all three

surgeries accounting for 92% in total. Whereas,

Williams33, Ebling, et al34, Caspar, et al35, and Findlay

et al37, have reported success rates ranging from 73 to

86%.

SUMMARY

The mean age was 49.85±8.75 years ranging from

40 to 72 years. Maximum patients were from fourth

decade of life. Male gender was predominant. The

mean age for male patients was found to be 49.84±8.58

years. All the patients had radicular pain, 26 out of 67

patients had left sided radiculopathy and right-sided

radiculopathy was observed in 21 patients whereas 20

patients had bilateral radiculopathy. Most of the

surgeries were done in the patients of age group of

fourth decade.

Maximum 42% of patients were operated by

laminectomy, 33 % patients were operated by

microscopic discectomy and minimum 25% of patients

were operated with microendoscopic discectomy.

Laminectomy group patients had higher mean age

54.25±9.656 years as compared to microscopic and

microendoscopic surgery group 46.5±6.940 and

46.95±6.088 years respectively. L4-L5 level was the

most common level to get involved and accounted for

72% of total single level surgeries.

The mean VAS scores of pre-operative, post-

operative and 6 months follow up significantly reduced.

The mean oswestery scores for pre-operative, post-

operative and 6 months follow up were compared and a

significant change was observed. The mean hospital



stay for microendoscopic discectomy was less as

compared to other methods.

Complications in all three surgeries were observed,

laminectomy had maximum number of complications, 6

patients did not had pain relief, dural tear was observed

in 3 patients, however 3 patients had superficial

surgical site infections, discitis was observed in 2

patients, however 1 patient had reherniation. Whereas,

only 2 patients did not have pain relief after

microscopic surgery, superficial infection was observed

in 1 patient, however 1 patient had discitis and 1 patient

had reherniation. However, only 1 patient did not

relieve of pain after micro endoscopic discectomy.

Conclusion Minimally invasive techniques in all areas of

surgery have gained momentum in recent years. Spinal

surgery has been no exception. Unfortunately,

minimally invasive techniques have often been equated

with minimally effective procedures. The procedure

involving tubular instrumentation and technique is an

attempt to allow for a standard familiar microsurgical

discectomy to be performed using standard

microsurgical techniques via a minimally invasive

approach.

We understand that the micro endoscopic

discectomy and microscopic discectomy techniques are

superior to the standard discectomy technique for the

treatment of single level lumbar disc herniation’s with

regard to pain relief, clinical outcome and functional

outcome, volume of blood loss, systemic repercussions,

and duration of hospital stay. However, technical

expertise and learning curve of the technique could be

the limitation.

The advantages of MED over SD include small

incision, better cosmesis, early ambulation, less

postoperative back pain, less blood loss, short hospital

stay, less analgesics, short time to return to work and

thus less cost of treatment.

Conflict of Interest: None

Source of Support: Nil

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F, Woolf A, Vos T, Buchbinder R. “A systematic review

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http://www.nlm.nih.gov/medlineplus/backpain.html.

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Evaluation of Degenerative Lumbar Disc Surgeries